Newbie would like advice about equipment

gasparama · Post by **gasparama** » Sun Jun 24, 2007 7:48 pm

I've been reading this message board for about 10 days and the information you give each other is pretty impressive. Maybe, some of you can offer some advice.

A few weeks ago, my podiatrist sent me to a sleep specialist who indeed thought that I have apnea. He arranged for me to set up a sleep study, but there were no times available until July 10. Because he was concerned that I was leaving in a few days for a week in the mountains, he had me spend the night attached to a loaner oxymeter which revealed that my oxygen was dropping low about 40-52 times an hour. Consequently, he prescribed Series M Basic and an Activa mask. (There is no way I can describe how much better I felt after the second night.)

What I want to know is if it would be a good idea to get a more upgraded machine, and why. I've been reading your posts with interest and need to know what stats are important for the user to monitor. And what argument should I use with my RT when I ask her to contact the doctor about changing? I monitor blood glucose daily so that I can be proactive in the treatment of diabetes. Shouldn't it be the same with OSA?

Thanks for your imput,
Jane

snoregirl · Post by **snoregirl** » Sun Jun 24, 2007 7:54 pm

Interesting post. First your " podiatrist" sent you to a sleep doctor? How unusual. But however you got there great.

You describe the machine as a M series Basic. I don't know of any machine by that name so I will assume you mean M series Plus.

How did the doc set your pressure without a titration study or at least a trial on an APAP? Seems like he licked his finger and stuck it up in the air and felt the wind!

In your situation without a sleep study you need a machine with data.

You don't mention insurance. Is your insurance worth it? If you will end up paying more than $600 or $700 in copay and/or deductable, then consider getting that prescription and see about buying an APAP online. If your insurance is good and you will pay little out of pocket, then ask you doc how he figured what to set it at with no data.

It is great that it is helping already, but to get the best treatment you possibly can you should have some data, either a sleep study titration or an APAP at home.

Good luck.

MLefholtz · Post by **MLefholtz** » Sun Jun 24, 2007 9:03 pm

snoregirl wrote:
How did the doc set your pressure without a titration study or at least a trial on an APAP? Seems like he licked his finger and stuck it up in the air and felt the wind!

It is great that it is helping already, but to get the best treatment you possibly can you should have some data, either a sleep study titration or an APAP at home.

Hi Jane. I agree with snoregirl. I purchased my machine outright from cpap.com. I was fortunate in that I bought my machine just a few days before cpap.com stopped selling the software. I bought a "discount bundle" including the machine, heated humidifier, software and smart card reader.

The main reason I bought an auto cpap machine is that I really didn't trust that the sleep clinic and doctors got my titration right. As it turned out, my titrated pressure of 9 was spot on. Was it worth it for that piece of mind? To me it certainly was. In practice, I run my machine in straight cpap mode with cflex set at 3.

Seems to me, you have a much more serious reason than I did for getting some data. Good luck. I know it will be more difficult for you to hunt up the software, but I think it will be well worth it for you. This is my personal opinion, I'm not related in any way to any medical profession.

Mike

ozij · Post by **ozij** » Sun Jun 24, 2007 9:09 pm

Meet the M-Series Family

and
http://remstarbasicmseries.respironics. ... ations.asp

Respironics' M series basic, according to their site, it the one the doesn't have C-Flex. C-Flex starts with the Plus.

C-Flex is an exhale pressure relief comfort feature added to the other Resprinics machines that can be turned on and off at will.

The if you're feeling well with the setup you have - then rest assured that it's giving you good therapy.

The nice things about smarter machines is that some of them have software that lets you know how many breathing obstruction, semi-obstructions and snores the machine detected and managed to resolve. - And some of them also change their pressure according to the events they detect.

Those that change their pressure are called automatic machines - APAP for short - could it be that an APAP was used on your second night as a basis for perscription?

Monitoring nightly breathing events is not as crucial in OSA as monitoring glucose levels is in diabetes. Certainly not if you feel well - when your level of obstruction (Apnea Hyponea Index =AHI) is too high, you feel it immediately - not much guesswork about that.

That said, I opted for an APAP with software, and while no longer checking my results every morning (2 plus years on it) I still do every now and then, and have made some changes as time went by. Mine is not made by Respironics, and has no exhale relief - but it does have software, and using the software helped me find my comfot level - my titration night in the lab wasn't that good...

An APAP can be run as a CPAP (non-self adjusting) - which is good, since some people are actually bothered by the machine's varying pressure. A CPAP cannot be run as an APAP - so if a person's needs vary during the night or between nights, the CPAP can't handle that - even it is an advanced, data reporting one.

Welcome to the board, Jane. Click the yellow light bulb (our collective wisdom) and the CPAP FAQ icons for more info.

O.

Linda3032 · Post by **Linda3032** » Sun Jun 24, 2007 9:21 pm

Ditto to all the above info. And especially, "How the heck can a doctor prescribe a cpap without knowing what pressure to start you out at?"

The doctor could be doing you more harm than good !!!!!!!!!!!!!!

Be sure to tell the sleep lab to put you on standby in case of a cancellation.

socknitster · Post by **socknitster** » Sun Jun 24, 2007 9:21 pm

Are you still going for the sleep study on July 10? I would. It would be helpful to know if you have periodic limb movement or central apnea as well. You say you feel better and that is AWESOME!, but I would want to have my treatment OPTIMIZED and have all the facts at hand.

I would also want a better machine and at the very least have the pro version that you can read the info on the screen--even if you decide not to go the software route, it is reassuring to have SOME feedback in the morning about how you are sleeping, even if it is just general stats.

Jen

gasparama · Post by **gasparama** » Sun Jun 24, 2007 9:46 pm

It's so good to hear from all of you. Let me explain that my podiatrist is really on top of his game and told me that neuropathy is agrevated by lack of sleep. The nerves heal and "settle down" during sleep. He wanted to know if my treatment could be augmented by treatment of sleep apnea if that applied

This is getting wordy, but my insurance provider determines the sleep center that will evaluate me, and that center calls for a visit with the sleep specialist first. My insurance cannot be billed for my equipment until I have the sleep study done, so that step is a necessity. It may be too late for me to get another machine unless I pay for one out of my pocket. I'll talk to the RT at the DME provider tomorrow.

The doctor had the pressure set at 10 until he knows where to have it set permanently. My RT said that he's usually correct, so I'll know for sure in a few weeks. The oxygen study did reveal a problem. And my husband has been telling me for the last few year that I gasp all night and sometimes kick my legs. He's been thankful for the last week of quiet nights.

Before I got my little air pump, I was sleeping off and on all day. I can hardly remember our vacations for the past 30 years because I've slept through them all. Woohoo, last week, I saw all the scenery! The biggest problem at this time is the mask. But, another can be tried.

I'll report back the results of trying to get a more advanced machine.

Jane

blarg · Post by **blarg** » Sun Jun 24, 2007 11:00 pm

Yeah, when they went to schedule me for a sleep study I got to go in 2 weeks early because I asked to be put on the cancellations list.

Elle · Post by **Elle** » Sun Jun 24, 2007 11:59 pm

would a pressure of 10 do her harm if it is determined that she requires less once she gets the study? What are the effects of a pressure set too high I am wondering?

rested gal · Post by **rested gal** » Mon Jun 25, 2007 1:39 am

I think your podiatrist was a very smart doctor to send you to a sleep specialist.

I think the sleep specialist was a very smart doctor, too, to order the overnight oximetry screening since there was going to be a rather long wait before you'd be able to get a full sleep study. He was doubly smart to put you on a cpap at 10 cm when the oximetry test came back showing your O2 sats were dropping during sleep.

Sure, it would be better to get a full PSG sleep study right away. But since that couldn't be done right then and you were going on a trip to higher altitudes, I think the sleep doctor made a wise decision to have you go ahead and get started on cpap at a pressure of 10. Statistics have shown that that pressure works very well for most people. If it's more than you actually need, it's a pressure that's very unlikely to harm a person. If it's not quite enough pressure, it's certainly better than no treatment at all.

If you want to be proactive about your own treatment (and it sounds like you probably do) then a machine that will provide data you can download to your own computer is very good to have.

If you'll be sticking with a cpap machine like the one you have now, the step up to get more data will be the M series Pro with C-Flex. If you'd like to have a more advanced machine than straight cpap, I'd get the M Series Auto with A-Flex. It can also be run in straight cpap mode, so it would be like having two machines in one.

It's the doctor (not the RT) you'll need to convince to write you an Rx for "autopap." Or, if you're willing to buy a machine out of your own pocket and not bother with jumping through the hoops of dealing with insurance and home health care store Rx requirements, your current prescription for "cpap @ 10 cm H2O" will let you buy an autopap from an online store like cpap.com. That's because an autopap IS a "cpap" machine. An autopap is a cpap machine with an auto-titrating feature you can turn on, or not, as you please.

Sounds like you're off to a good start since you said: "There is no way I can describe how much better I felt after the second night." Hope you have continued good treatment and great sleep!

ozij · Post by **ozij** » Mon Jun 25, 2007 6:25 am

Diagnosis and initial management of obstructive sleep apnea without Polysomnography

Annals of Internal Medicine 2007; 146:157-66

A Randomized Validation Study
Alan T. Mulgrew, MB; Nurit Fox, MSc, CCRP; Najib T. Ayas, MD, MPH; and C. Frank Ryan, MB

6 February 2007 | Volume 146 Issue 3 | Pages 157-166

Background: Polysomnography (PSG), despite limited availability and high cost, is currently recommended for diagnosis of obstructive sleep apnea and titration of effective continuous positive airway pressure (CPAP).

Objective: To test the utility of a diagnostic algorithm in conjunction with ambulatory CPAP titration in initial management of obstructive sleep apnea.

Design: A randomized, controlled, open-label trial that compared standard PSG with ambulatory CPAP titration in high-risk patients identified by a diagnostic algorithm.

Setting: A tertiary referral sleep disorders program in Vancouver, British Columbia, Canada.

Patients: 68 patients with a high pretest probability of moderate to severe obstructive sleep apnea (apnea–hypopnea index [AHI] >15 episodes/h) identified by sequential application of the Epworth Sleepiness Scale (ESS) score, Sleep Apnea Clinical Score, and overnight oximetry.

Intervention: Patients were randomly assigned to PSG or ambulatory titration by using a combination of auto-CPAP and overnight oximetry. They were observed for 3 months.

Measurements: Apnea–hypopnea index on CPAP, ESS score, quality of life, and CPAP adherence.

Results: The PSG and ambulatory groups had similar median BMI (38 kg/m2), age (55 years), ESS score (14 points), and respiratory disturbance index (31 episodes of respiratory disturbance/h). Each episode is determined by a computer algorithm based on analysis of oxygen saturation measured by pulse oximetry. After 3 months, there were no differences in the primary outcome, AHI on CPAP (median, 3.2 vs. 2.5; difference, 0.8/h [95% CI, –0.9 to 2.3]) (P = 0.31), between the PSG and ambulatory groups, or in the secondary outcomes, ESS score, Sleep Apnea Quality of Life Index, and CPAP. Adherence to CPAP therapy was better in the ambulatory group than in the PSG group (median, 5.4 vs. 6.0; difference, –1.12 h/night [CI, –2.0 to 0.2]) (P = 0.021).

Conclusions: In the initial management of patients with a high probability of obstructive sleep apnea, PSG confers no advantage over the ambulatory approach in terms of diagnosis and CPAP titration. The ambulatory approach may improve adherence to treatment. When access to PSG is inadequate, the ambulatory approach can be used to expedite management of patients most in need of treatment.

Conflict of Interest:
N.T. Ayas (Respironics Inc.), C.F. Ryan (ResMed Corp., Vitalaire Canada, Inc.).

My emphasis.

Editors' Notes

Context

Overnight polysomnography in a sleep laboratory is normal practice for diagnosing obstructive sleep apnea (OSA) but it is expensive and can delay diagnosis.

Contribution

The authors combined standard clinical scales and overnight home oximetry to ensure a pretest probability of OSA of 90% or greater. Sixty-eight patients were randomly assigned to usual care (polysomnography obtained before continuous positive airway pressure [CPAP]) or ambulatory management (start CPAP without doing polysomnography). After 3 months, the 2 groups had the same results on overnight polysomnography.

Cautions

The study was done in a single tertiary care center.

Implications

Most patients with a probability of OSA of 90% or greater do not require polysomnography before starting CPAP.

—The Editors

The PDF version of this article will be available for free in August, 6 months after the initial publication.

_________________

CPAPopedia Keywords Contained In This Post (Click For Definition): Titration, CPAP, AHI, auto

Guest · Post by **Guest** » Mon Jun 25, 2007 1:38 pm

[Conclusions: In the initial management of patients with a high probability of obstructive sleep apnea, PSG confers no advantage over the ambulatory approach in terms of diagnosis and CPAP titration. The ambulatory approach may improve adherence to treatment. When access to PSG is inadequate, the ambulatory approach can be used to expedite management of patients most in need of treatment.quote]

This was a great read for me. My doctor has been ordering and interpreting sleep studies for many years, and spent an hour talking with me about OSA and treatment. I have complete confidence that he knew what he was doing when he prescribed the CPAP after seeing the results of the oximeter study. Even though this is not a scientific study, my experience bears out that using the machine for a trip to a higher altitude was quite the thing to do. We have family in Colorado, so we go there at least once a year. Our family joke is that this was the first time I'd ever seen the mountains because I was always asleep before my husband drove past the first 7-11 store.

I did see the RT this morning. He gave me two new masks and a chin strap at no charge. He told me that if my needed pressure is 12 or above after I finish the study, then the doctor will want me to have an autopap. At this time, I don't need one. I now know how to read the information on the screen and can get software if I need or want it. However, my leak rate is not available. Anyway, an hour with the RT is a useful thing.

Blah, blah,blah, I have one more thing to tell you readers: I think sleep apnea was formally identified about 1965. I never heard of it until 1975 when my father died from a heart attack. While he was in the hospital, the nurses showed me how he quite breathing about every other minute. But that was all there was to it. There was no treatment, no warning of the danger. This man was a very active 68 year old. I really believe that OSA was a big factor in his death, so I'll never whine about the inconvenience of this treatment. We "hoseheads" are the fortunate ones!

ozij · Post by **ozij** » Mon Jun 25, 2007 9:26 pm

We "hoseheads" are the fortunate ones!

You are so right!

O.

Patrick A · Post by **Patrick A** » Mon Jun 25, 2007 11:41 pm

rested gal wrote:I think your podiatrist was a very smart doctor to send you to a sleep specialist.

I think the sleep specialist was a very smart doctor, too, to order the overnight oximetry screening since there was going to be a rather long wait before you'd be able to get a full sleep study. He was doubly smart to put you on a cpap at 10 cm when the oximetry test came back showing your O2 sats were dropping during sleep.

Sure, it would be better to get a full PSG sleep study right away. But since that couldn't be done right then and you were going on a trip to higher altitudes, I think the sleep doctor made a wise decision to have you go ahead and get started on cpap at a pressure of 10. Statistics have shown that that pressure works very well for most people. If it's more than you actually need, it's a pressure that's very unlikely to harm a person. If it's not quite enough pressure, it's certainly better than no treatment at all.

If you want to be proactive about your own treatment (and it sounds like you probably do) then a machine that will provide data you can download to your own computer is very good to have.

If you'll be sticking with a cpap machine like the one you have now, the step up to get more data will be the M series Pro with C-Flex. If you'd like to have a more advanced machine than straight cpap, I'd get the M Series Auto with A-Flex. It can also be run in straight cpap mode, so it would be like having two machines in one.

It's the doctor (not the RT) you'll need to convince to write you an Rx for "autopap." Or, if you're willing to buy a machine out of your own pocket and not bother with jumping through the hoops of dealing with insurance and home health care store Rx requirements, your current prescription for "cpap @ 10 cm H2O" will let you buy an autopap from an online store like cpap.com. That's because an autopap IS a "cpap" machine. An autopap is a cpap machine with an auto-titrating feature you can turn on, or not, as you please.

Sounds like you're off to a good start since you said: "There is no way I can describe how much better I felt after the second night." Hope you have continued good treatment and great sleep!

Rested Gal you di it again, right on the head.

Machine